Remember, according to the ICHIA Customer Service Representative I called after receiving Neil's first response to my questions, if a vaccination is proven as "medically necessary" by the primary care or infectious disease physician, then it is covered under ICHIA.

The final question I asked Neil concerned other sources for vaccinations.

Are there other agencies, organizations, or programs which would fund the cost of any one of the less common vaccinations mentioned, yet still allow the Consumer to receive the vaccine from their primary care or infectious disease physicians?  Many primary care and/or infectious disease physicians do not like their HIV+ clients to receive vaccines from "free" or "low-cost" clinics simply because the primary or infectious disease physician cannot monitor the HIV+ client since by the very nature of the of the disease, the Consumer's immune system is already compromised.  Many physicians like to perform blood test such as viral loads and cd4 counts before and after the vaccination to ensure the Consumer's health is not adversely affected by the vaccine.

[This would be best answered by the Consumer's Care Coordinator as I as the HIV Medical Services Program Manager, am not always aware of all other sources potentially available to Consumers.]

So then, what can the Consumer take away from the Part 2 of the article "To Vaccinate or Not to Vaccinate" in regards to coverage provided by ICHIA on the less common vaccines (i.e. tetanus, hep a, hep b, or TB)?

Well the best answer to this question would be to repeat the answer I received from the ICHIA Customer Service Representative when I asked the aforementioned questions on vaccination coverage: 

If proven medically necessary by the Consumer's primary care or infectious disease physician, then yes it is covered.  If it is routine, then it will not be covered.

If you are currently enrolled in the Care Coordination Program and have questions regarding coverage or other questions regarding your ICHIA insurance policy, you may contact Neil by sending him an email at ncarnes@isdh.IN.gov.

I personally want to thank the Customer Service for ICHIA, but most especially Mr. Neil Carnes, HIV Medical Services Program Manager for the Indiana State Department of Health, Division of HIV/STD, for his time and patience over last few weeks as I have inundated him with a plethora of questions regarding vaccinations and ICHIA coverage. 

SPECIAL NOTE:  All comments made by or implied by the author are strictly that of the author and does not in any way represent the opinions or comments of the Indiana State Department of Health, the Indiana Consumer Advisory Board, the Advisory Council,  nor the Indiana Comprehensive Health Insurance Association (ICHIA).  Any inferences made by the reader are only determined by the reader and the author in no way implies any definitive answer.
____________________________________________

Jeff Wolfe serves as the Central Area Representative for the Indiana Consumer Advisory Board and Vice-Chair for the Comprehensive HIV Services Planning and Advisory Council.  Jeff holds a BA degree in Sociology with a minor in Medical Sociology from Indiana University.  Jeff has served also as the District/Region 4 Representative back in 2006. You can reach Jeff by sending an email to jeff.wolfe@indianacab.org. 

DISCLAIMER:  the information provided herein is for informational purposes only.  Consumers should always consult their physician regarding needed and required vaccinations to protect their health, whether or not such services are provided by insurance.

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Two weeks ago, I covered Part 1 of the article entitled "To Vaccinate or Not to Vaccinate" 'A Consumer's questions regarding Swine Flu and other vaccinations and insurance ICHIA coverage'
 
To read the full Part 1 of this article, go the CAB HOME PAGE NEWS submenu under the LINKS tab at the top of the button and go to the CAB HOME PAGE NEWS for Week Ending 09/04/2009. 

To summarize Part 1 of this article, a Consumer Advisory Board (CAB) Representative covered a request from a consumer for help because the consumer had been put on a "CASH ONLY" basis by his primary care physician's billing office for lack of payment on a standard tetanus vaccination.

Refreshing the reader's memory, the CAB Representative thought that couldn't be right. How could an insurance company deny vaccination coverage to immune compromised consumers under the state's high risk policy?  Secondly, the CAB Representative wondered who was responsible for notifying consumers when the Care Coordination provider received notification of changes to insurance policy for ICHIA?

Last week's article addressed the issue regarding the more common vaccinations (such as flu shot and pneumovax) and what is covered under ICHIA.  This week will be a continuation of that story addressing answers to coverage regarding the less common, yet still vitally important, vaccinations which may from time to time be medically necessary as determined by the Consumer's primary care or infectious disease physicians.  

Again I contacted Neil Carnes, HIV Medical Services Program Manager for ISDH, Division of HIV/STD and asked the following questions to help clarify the first issue discussed in this article - are the less common vaccinations covered under ICHIA. In particular I requested coverage information on vaccinations for tetanus, TB, Hep A and Hep B.

I asked Neil the same questions regarding the less common vaccinations which I asked in Part 1 of the article on the more common flu vaccination and pneumovax.  Rather than providing answers to each of the less common vaccinations and coverage provided under ICHIA, Neil responded with the following:

I have attached the ICHIA policy regarding coverage, which details what is and is not covered.  What I do know is that currently ICHIA only pays for two vaccinations:  seasonal flu[standard flu shot] and pneumococcal [standard pneumovax vaccination].  ICHIA is a "medically necessary" based policy that typically excludes preventative and routine services, such as vaccinations (preventative by design).  Any additional questions should be directed to ICHIA Customer Service at 1-800-552-7921 for ICHIA determines what is and is not covered, not ISDH.

You can obtain a copy of the latest version of ICHIA policy by going to the Consumer Advisory Board's (CAB'S) website's "downloads" tab and then locating the ICHIA Policy document and click on it to start the download, or you can click here to download now. 

After receiving Neil's response, I contacted the ICHIA Customer Service at the number listed in his response, provided my ICHIA ID number and my birthdate.  I was then routed to a Customer Service Representative.  I the proceeded to ask the following questions regarding the less common vaccinations and ICHIA's policy regarding coverage.  Here are the Customer Service Representative's responses:

Does ICHIA cover vaccinations for tetanus every 10 years?

If proven medically necessary by the Consumer's primary care or infectious disease physician, then yes it is covered.  If it is routine, then it will not be covered

Does ICHIA cover Hep A and Hep B vaccinations if required by the Consumer's primary care or infectious disease physician?

If proven medically necessary by the Consumer's primary care or infectious disease physician, then yes it is covered.  If it is routine, then it will not be covered.

Does ICHIA cover TB vaccinations if required by Consumer's primary care or infectious disease physician?

If proven medically necessary by the Consumer's primary care or infectious disease physician, then yes it is covered.  If it is routine, then it will not be covered.

Does ICHIA cover HPV vaccination if required by the Consumer's primary care or infectious disease physician?

If proven medically necessary by the Consumer's primary care or infectious disease physician, then yes it is covered.  If it is routine, then it will not be covered.

Though the Customer Service Representative's answers seemed almost like a broken record, it did make one thing very apparent - if I want my vaccinations to be covered by ICHIA then my primary care or infectious disease physician needs to prove the vaccination(s) medically necessary.  This shouldn't be a stretch since I have an immune compromised disease.

I then had a few other questions for Neil which he graciously provided for me.

If not for any one of the vaccinations listed (tetanus, hep a, hep b, hpv) would not be covered by ICHIA, would any one of these less common vaccinations be picked up by fund managed by ISDH to cover gaps?

No.

If not, what are ISDH's recommendations to Consumers in Care Coordination for receiving vaccinations which are not covered, but required by his or her physician?  It does not make financial logic that ICHIA would not cover a vaccine for an immune compromised individual, rather than have huge costs associated with hospitalization if a Consumer did not receive a vaccine because it was not covered by ICHIA (since by the very nature of the requirements for Care Coordination include that Consumers be at or below 300% above the poverty level).

ICHIA did pass the inclusion of additional preventative measures back in 2007 (such as additional vaccinations), yet when they did the financial burden assessment on covering these additional...[vaccinations]... [ICHIA] realized that based upon the money they take in they cannot afford to cover these other...[vaccinations].  [The] only way [ICHIA] could have added these additional preventative services would have been to increase the premium or cut other services their enrollees.